3: disorders of the orbit and systemic associations

ptosis

drooping of the upper eyelid. occasional visual compromise often gets wose with reading at night

both congenital ( got from birth) or acquired

in babies if obstructive can impair visual development and lead to amblyopia or anisometriopia

causes of ptosis

myogenic

aponeurotic

neurogenic

mechanican

traumatic

pseudoptosis

neurogenic causes of pstosis

nerve issue due to paresis or disease eg horners syndrome

tosis, miosis and anhydrosis

myogenic causes of pstosis

nearly always congentical .

present at birth and is caused by restriction of levator palpebrae superiorisis. including from conditions such as myathenia gravis - automimmune condition that causes muscle weakness and difficulty controlling eyelids and eye movements

children have neuroplastic cortex - brain more easy to adapt

aponeurotic causes of ptsosis

defect of the levator muscle, or effect of aging, repetitive eye rubbing , use of rigid contact enses, tauma or prvious intraocular surgery

mechanical causes of pstosis

effect of a mass, prior trauma or scar tissue

forieign body or retained contact lens in upper fornix or forniceal inflammation

what are the following tests done for pstosis

levator function assessment

pupil assessment

ocular motility

assessment for jaw winking syndrome- nerve related to opening jaw relates to nerve opeing the eye

thyroid eye disease

retraction of the upper eyelids with lateral flare and eyelid lag on downward gaze, lagopthalmos.

thyroid issue scan occur at any ages but usually more in women and those over 40. leads to a visible goitre

thyroid gland

used to regulate some of the bodys hormones and metabolism, located in the neck, it is an endocrine gland eaning it releases hrmones into the blood stream

what is thyroid gland used to regulate for

regulates metabolism

regulating heart rate

food digestion

breathing

fertility

helps process bodily calcium

endocrine gland: releases hormones into the bloodstream

exocrine gland: releases into a duct

what systemic issues occur when you have n over reactive or under reactive thyroid

temperature tolerance

weight changes

heart rate changes

mental staus and hormonal changes

hypothyroidism

causes a reduction in the metabolic effects

hyperthyroidism

causes an increase in the metabolic effects

rapid pulse hot and dry skin

enlarged thyroid gland (goiter)

weight loss ]

ocular synptoms of thyroid eye disease

foreign body sensation, redness, tearing, photophobia

upper eyelid retraction tends to develop

lateral flare

prominent eyes

eyelid swelling

treamtents of thyroid eye disease

px take levothyroxine to supplement the lack of this either by the condition of hypothyroidism or the treatment of hyperthyroidism which is surgical removal or radiation to reduce its inital functino and then supplement this

thyroid eye disease common causes

via autoimmune condition known as graves disease and this can cause hyperthyroidism and associated conditions which can affect the eye

TED signs

can appear asymptomatic or red and painful

px can get double vision

can get upper lid retraction and proptosis ; bulding forward of eyes

px can lose their sight and visual fields through optic nerve difficulties

dryness

impaied vision

more signs of TED

lid retraction occurs in 50% of those with graves

due to sympathetic overstimulation of the lid muscles.

px may complain about appearance, or dry eyes and exposure to cornea, raised lid on downgace another warning sign - if px looks down and lid still looks retracted then likely TED

proptosis is an extensino of this where eyes begin to bulge, unilateral, bilateral or aymmetric- due to metabolic activity increases, over production of the fat tissue of orbit behind eye. due to this it compresses the eye muscles and optic nerve causing vision loss

progress to restrictive myopathy, and optic neuropathy

referral to HES urgently if any of thsi is suspected

orbital infections

preseptal cellulitis and orbital cellulitis

mostly seen in children

preseptal cellulitis

infection of the subcutaneous tissue of the eyelid and skin around the eye

more anterior

less serios than orbital cellulitis , but moderate risk of progressing to orbital so urgent referral needed

bacterial infection usually the case, and usually staphylococcus or streptococcus, and usually spreads from infection/skin trauma , some bite, or conjunctivitis, acute hordeolum

signs of preseptal cellulitis

eyelid appears swollen firm and tender, ad in moderate pain

red eye swelling can appear very severe and they may have a fever

assume it isnt preseptal until you confirm that there is no proptosis, VA unaffectedm pupil reactions are equal and ocular motility isnt impaired

orbital cellulitis

an infection of the soft tissues behind the orbital septum which are sight and life threatening if not treated quickly

usually starts as a sinus infection which then spreads

px has fever and lot of pain

VA reduction and colour vision between eyes, any pupil RAPD is diagnositic

much chemosis and redness and swellnig of conjunctival haemorrhage, proptois presen but may be hidded due to lid swelling

px hospitalised with IV antibiotics and any abcess will be drained with surgery

what exam is done with those with orbital cellulitis

exam will occur with a CT and MRI to assess situation

trauma

lid laceration and black eyes

any subvonjunctival haemorrhage or bleed needs to be assessed to identify extent of bleeding

any open wound on lid needs urgent treatment

diinfection and closure is important to prevent risk of orbitla cellulitis

observe foreign bodies

effects of blunt trauma

blow out fracture with associated enopthalmos, motility issues, and potential diplopia ; inferior rectus muscle gets stuck so eye is restricted from looking up

some may give corneal abrasions , tears in corneal layers, visible with fluorescein

look out for hyphaema or impact on iris such as a displaced pigment iridiodialysis

hyphaema

blood collected in the anterior chamber and due to gravity it deposits at the bottom

sticky iris due to trauma

in severe trauma cases the iris might disappear

seidels sign

penetrating injury of the cornea due to trauma

symptoms vary from nothing/mild visual reduction to severe pain and light sensitivity

may appear normal or may have circulinear injection with a reduced IOP

use fluorescein to show a waterfall like effect. requires same day referral

iris prolapses

can occur after surgery or a perforated cornea , or in the case of trauma or infection

px will have a foreign body sensation, pain and epiohora

needs emergency same day referral. not to take eye drops ad will need surgery to correct

tumours

look for irregular shapes, raised areas, growth and invasive approach to other tissues for soething malignant

refer within 4-6 weeks

treatment incolves excisino, blood assessment and body assessment for metastasic possibilities. ocular tumors can be primary or secondary sites for malignancy

iris tumours

can also have naevi here

can be flat or raised, and there can be several or few

greater risk of malignancy so need to monitor and observe lifelong change

present at a younger age, inferior iris location, light skin and iris colour, melanosis elsewhere and any odd features such as diffuse edges or blood vessel/bleeds on naevus

refferred urgently and are potentially able to metastasise

diabetes

endocrine condition where body either doesnt produce enough insulin ( type 1) or becomes resistant to insulin (type 2)

type 1 diabetes

immune system attacks and destroys the cells in the islet of langerhans in the pancreas, and thus you do not have insulin and this can cause issues with sugar control

type 2 diabetes

the body either doesnt produce enough insulin or the cells dont react to the insulin and thus you get the same issues with sugar control

cause from diabetes

both of these cause issues to the blood vessels in the bdy but also the nerves, because sugar is toxic

also bevause your blood becomes sticky, as the amount of glucose attached to it is too high and raises inflammatory markers

loss of efficent circulation and innervation means you are at greater risk of inflammation, infection and damage to small capillaries and smaller cells of the body

diabetes damage to the anterior eye

cataracts

corneal sensation lossneuropathy

dry eye

iris neovascukarisation

slow healing of tissues - higher risk of infections

less regulated lid control

greater risk of infarcts and bleeds

risk factors of diabetes thus affecting the eye

poor control of blood sugar

length of time with diabetes

greater BMI and/other systemic conditions such as hypertensino

asian/black ethnicity

older age